1.0 Purpose
This TRICARE pilot project will evaluate
the success of collaboration between Managed Care Support Contractors
(MCSCs), network EDs, and inpatient MTFs to offer the opportunity
to transfer clinically stable, qualified Uniformed Services beneficiaries
from civilian EDs to an inpatient MTF/eMSM for inpatient care and
treatment. The outcome of the pilot project would enable the Government
to consider operational and financial changes necessary to further
Military Health System (MHS) goals to optimize the capabilities
of the Direct Care (DC) system and support medical readiness, enhance
MTF/eMSM provider proficiency and graduate medical education programs,
responsibly steward taxpayer dollars, reduce beneficiary costs,
and enhance beneficiary satisfaction.
2.0 Eligibility
Policy
2.1 Participating
Beneficiary:
2.1.1 Any
Uniformed Services beneficiary who shows as TRICARE eligible in
Defense Enrollment Eligibility Reporting System (DEERS) except for
beneficiaries not eligible for care in MTFs/eMSMs; and
2.1.2 Voluntarily
elects transfer to a local inpatient MTF/eMSM once stabilized in
a civilian ED. Parents, legal guardians, or authorized personal
representatives may elect transfers on behalf of others.
2.2 EXCEPTION: If
clinically stable, members on active duty greater than 30 days should
be asked to agree to transfer, but may be ordered to transfer depending
on the circumstances.
3.0
Ambulance
Policy
3.1 A request by either a civilian ED
or MTF/eMSM shall, for purposes of this Pilot, constitute an “order”
under TRICARE Policy Manual (TPM),
Chapter 8, Section 1.1, to serve as authority
for TRICARE payment of a not-medically necessary transport to an
MTF.
3.2 If Medicare is primary payer and the
claim is denied by Medicare because the civilian facility has appropriate
facilities to treat the patient, TRICARE will cost share on the
claim. See TPM,
Chapter 8, Section 1.1.
3.3 If Medicare
is primary payer and the claim is denied by Medicare as not being
medically necessary, TRICARE will cost-share on the claim so long
as it is ordered by civilian or military personnel. See TRICARE
Reimbursement Manual (TRM),
Chapter 1, Section 14, paragraph 3.6.4.
4.0 Responsibilities
4.1 Participating
MTFs/eMSMs
4.1.1 Collaborate
with regional contractor to identify and educate civilian network
facilities and their ED staff on the goals and benefits of participating
in this pilot project.
4.1.2 Determine clinically appropriate MTF/eMSM
capabilities and capacities to accept clinically stable beneficiaries
for transfer.
4.1.3 Provide contractor and/or civilian EDs
with information regarding MTF/eMSM clinical capabilities, MTF/eMSM
patient transfer hotline information, MTF/eMSM patient transfer
process, and beneficiary-focused educational materials including
a written beneficiary/personal representative acknowledgment of
cost-sharing and other financial obligations if they transfer to
an MTF/eMSM versus admitted to a civilian facility, to be given
to beneficiaries.
4.1.4 Staff a 24-hour patient transfer hotline
to receive requests for patient transfers.
4.1.5 Respond to notifications of potential
transfers from civilian EDs.
4.1.5.1 Confirm eligibility
and determine inpatient clinical capability and capacity to accept
the beneficiary for admission and treatment.
4.1.5.2 Provide a verbal
response within 30 minutes of the notification from the civilian
ED.
4.1.5.3 If MTF/eMSM inpatient capability
and capacity exists and both the attending civilian physician and
the accepting MTF/eMSM physician agree that the beneficiary is clinically
stable and can be safely transported to the MTF/eMSM based on the
medical status of the beneficiary and the clinical appropriateness
of the transfer, the MTF/eMSM shall initiate a request to dispatch
ambulance transportation within 30 minutes of the acceptance decision
(when ambulance transport is clinically required). Based on local
procedures, the civilian ED may request dispatch of the ambulance.
4.1.5.4 If no MTF/eMSM
capability exists or the attending and receiving providers do not
agree the beneficiary can be safely transported to the MTF/eMSM
based on the medical status of the beneficiary and the clinical
appropriateness of the transfer, the beneficiary remains the responsibility
of the civilian ED to arrange appropriate care in a civilian facility.
4.1.6 Collect and
report on project workload and financial data as required by the
Defense Health Agency (DHA) Project Manager.
4.2 Regional
Contractor (East and West Regions Only)
4.2.1 Collaborate with MTF/eMSM pilot sites to
identify and educate civilian network facility staff on the goals
and benefits of participating in this demonstration.
4.2.2 Establish
processes with or within civilian network facilities to:
4.2.2.1 Identify eligible
and stable Uniform Services beneficiaries seen in EDs that require
inpatient admission.
4.2.2.2 Inform eligible
beneficiaries of the opportunity to be admitted to a nearby MTF/eMSM
for further treatment as an inpatient.
4.2.2.3 Share MTF-provided
educational materials to the beneficiary, to include full disclosure
and patient/personal representative written acknowledgment of their
cost-sharing and other financial obligations related to both remaining
at their present facility and transferring to an MTF. All educational materials
will be coordinated with DHA Communications Office.
4.2.2.4 If the
beneficiary desires to participate in the pilot project, notify
the appropriate MTF.
4.2.2.4.1 If both
the attending civilian ED physician and the accepting MTF/eMSM physician determine
the beneficiary can be safely transported to the MTF/eMSM based
on the medical status of the beneficiary and the clinical appropriateness
of the transfer, the civilian ED shall prepare the beneficiary for
transfer to the MTF/eMSM and provide appropriate transfer clinical
and administrative medical documentation. Based on local procedures,
either the MTF/eMSM or the civilian ED may request dispatch of an
ambulance when clinically necessary.
4.2.2.4.2 If there is
no concurrence between the providers for safe transfer or the MTF/eMSM declines
the transfer, the beneficiary remains the responsibility of the
civilian ED to arrange appropriate care in a civilian setting.
5.0
Pilot
Project Service Areas
5.1 Army:
Puget Sound eMSM - Madigan Army Medical Center, Tacoma, WA and Naval
Hospital Bremerton, WA; Womack Army Medical Center, Fort Bragg,
NC; San Antonio MHS e-MSM, San Antonio Military Medical Center,
Joint Base San Antonio, TX.
5.2 Navy: Naval Hospital Jacksonville, FL;
Tidewater eMSM - Naval Medical Center Portsmouth, VA and 633rd Medical
Group, Joint Base Langley-Eustis, VA.
5.3 Air Force: 60th Medical Group, David Grant
Medical Center, Travis Air Force Base (AFB), CA; 99th Medical Group,
Mike O’Callaghan Federal Medical Center, Nellis AFB, NV; 88th Medical
Group, Wright-Patterson Medical Center, Wright-Patterson AFB, OH;
and 96th Medical Group, Eglin AFB, FL.
5.4 National Capital Region eMSM: Walter Reed
National Military Medical Center, Bethesda, MD.
6.0 Beneficiary
Cost Liability
6.1 Beneficiaries shall be responsible
for all required TRICARE cost-shares or MTF/eMSM fees.
6.2 See
paragraph 3.0 for
ambulance related cost-shares and the potential for denied Medicare claims.
7.0 Pilot Cost
Avoidance
7.1 Government
and Contractor. Monetary cost avoidance occurs as MTF/eMSM admissions eliminate
the Government cost of inpatient TRICARE claims (facility and professional
fees). This is offset by costs to the Government for ambulance transfers
to the MTF/eMSM and the marginal costs of MTF/eMSM inpatient admissions.
7.2 Beneficiary.
Eliminates beneficiary cost-sharing of an inpatient TRICARE claim
but adds potential for cost-shares or denied claims relating to
ambulance transfers. See the TPM,
Chapter 8, Section 1.1 and the TRM,
Chapter 4, Section 4.
9.0 Effective
And Termination Dates
This pilot project is effective
for elective patient transfer requests from civilian EDs to designated
inpatient MTFs/eMSMs as of July 25, 2016. The pilot project shall
terminate on the last day of a Region’s current contract, or two
years from the start of the pilot project, whichever comes first.